Provider Demographics
NPI:1316473135
Name:DEBOLD, DOMINIQUE (PHARMD)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:DEBOLD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 COLLEEN DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-5512
Mailing Address - Country:US
Mailing Address - Phone:415-894-0128
Mailing Address - Fax:
Practice Address - Street 1:6247 GRAHAM HILL RD
Practice Address - Street 2:
Practice Address - City:FELTON
Practice Address - State:CA
Practice Address - Zip Code:95018-9723
Practice Address - Country:US
Practice Address - Phone:831-335-6403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76191183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist